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UNDERGROUND STORAGE TANK OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM ( Page -I of 1 ) Type of Action ❑ Installation Inspection ❑ Repair Inspection ❑x 36 Month Inspection I . FACILITY INFORMATION CERS ID Date of Overfill Prevention Equipment Inspection 3/ 13/2019 Business Name (Same as Facility Name or DBA-Doing Business As) 7 - Eleven #35355 Business Site Address City ZIP Code 3202 W Hammer Ln Stockton 95209 II . UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION Name of UST Service Technician Performing the Inspection (Print as shown on the ICC Certification .) Phone # Anthony Reyes 1 ( 916 ) 373 - 1166 Contractor / Tank Tester License # ICC Certification # ICC Certification Expiration Date 617238 8293772 9/ 16/2020 Overfill Prevention Equipment Inspection Training and Certifications (List applicable certifications.) OPW UST Phase 1 EVR Tech# 103920 III . OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION Inspection Method ❑x Manufacturer Guidelines (Specify) : Used : OPW Install & Maintenance Guidelines ❑ Industry Code or Engineering Standard (Specify) : ❑ Engineered Method (Specify) : Attach the inspection procedures and all documentation required to determine the results. # of Attached Pages TANK ID : (By tank number, stored product, etc.) 87 Gasoline 91 Gasoline Diesel What is the tank inside diameter? (Inches) 117 . 75 117 . 75 117 . 75 Is the fill piping secondarily contained ? 0 Yes ❑ No 0 Yes ❑ No ❑x Yes ❑ No ❑ Yes ❑ No Is the vent piping secondarily contained ? ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No Overfill Prevention Equipment Manufacturer(s) OPW OPW OPW What is the overfill prevention equipment response ❑x Shuts Off Flow ❑x Shuts Off Flow 0 Shuts Off Flow ❑ Shuts Off Flow when activated ? (Check all that apply.) ❑ Restricts Flow ❑ Restricts Flow El Restricts Flow ❑ Restricts Flow ❑ A/V Alarm ❑ A/V Alarm ❑ A/V Alarm ❑ A/V Alarm Are flow restrictors installed on vent piping? ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No At what level in the tank is the overfill prevention set to activate? (Inches from bottom of tank.) 103 . 375 103 . 375 104 What is the percent capacity of the tank at which the overfill prevention equipment activates ? 94 % 94 % 94 % Is the overfill prevention in proper operating condition ❑x Yes ❑x Yes Z Yes ❑ Yes to respond when the substance reaches the appropriate level? ❑ No (Specify in V.) ❑ No (Specify in V.) ❑ No (Specify in V.) It ❑ No (Specify in V.) IV. SUMMARY OF INSPECTION RESULTS Overfill Prevention Inspection Results ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail V. COMMENTS Any items marked "Fail " must be explained in this section. Any additional comments may also be provided here . Replaced all three droptubes with new. Inspector onsite to witness installation . VI . CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS INSPECTION I hereby certify that the overfill prevention equipment was inspected in accordance with California Code of Regulations , Title 23 , Division 3, Chapter 16 , Section 2637 . 2 and all the information contained herein is accurate . UST Service Technician Signature If the facility has more components than this form accommodates, additional copies of this page may be attached. CERS = Califomia Environmental Reporting System, ID = Identification, UST = Underground Storage Tank, ICC = International Code Council, AIV = Audible and Visual